Issue link: http://eyewitness.epubxp.com/i/783657
14 CLSA EyeWitness Winter 2017 I t's the all too common chief com- plaint: "my eyes feel scratchy, irri- tated, red" and so on. Foreign body sensation is a common issue encoun- tered by most eye care practitioners on a daily basis, and yet a standard "dry eye" diagnosis and treatment plan is often set in stone before the slit lamp is even turned on. Many of these long-suffer- ing patients are now receiving improved relief due to excellent new pharmaco- logic and procedural therapies. On the other hand, a small subset of patients with foreign body sensation are quickly misdiagnosed as evaporative or aqueous deficient dry eye, and the root anatomi- cal issue is overlooked. Three conditions that make up the bulk of these scenari- os can be easily identified and remedied once you know what to look for. Conjunctivochalasis is a condition in which there is redundant bulbar con- junctival folds, disrupting tear distribu- tion and surface anatomy. The excess conjunctiva often obliterates the inferior fornix, displaces the inferior tear menis- cus, and in severe cases, spills over the inferior lid margin obstructing the punc- tum. Recent research has shown that na- sal conjunctivochalasis is associated with the most severe symptoms, resulting in epiphora, foreign body sensation, and an increase in inflammatory biomarkers in the tear film. 1 The excess tissue can also complicate the fitting of scleral lenses in these patients due to the irregularity of the landing zone. Mild to moderate cases can be effectively managed with lubrica- tion and anti-inflammatory therapies. More severe cases may benefit from sur- gical management, often by cautery or excision in combination with amniotic graft transplantation. Lagophthalmos occurs when there is a lack of complete eyelid closure. It can Paul Hammond, OD Anatomical Masqueraders in Dry Eye Management be attributed to several different causes: nocturnal anatomical positioning, Bell's palsy, Grave's disease, history of blepha- roplasty, and more. Lack of complete eye- lid closure exposes the ocular surface and leaves it exposed to desiccating stress over time, leading to morning discomfort and redness. 2 A simple test to identify it is to in- still fluorescein and ask the patient to gen- tly close their eyes as if they were asleep. Inspect carefully for a gap in the interpal- pebral fissure and watch for an incom- plete blink upon command. Treatment options include lubrication, lid taping, moisture goggles, partial or full tarsorrha- phy, or gold weight implantation into the upper lid. Scleral lenses are an excellent option during the daytime hours for these patients with incomplete closure. A chronic and asymmetric papil- lary conjunctivitis is a significant find- ing pointing towards floppy eyelid syndrome. The more severe papillary reaction occurs on the side that touch- es the pillow; this is because the upper lid spontaneously everts, exposing the palpebral conjunctiva to frictional and abrasive properties of the patient's pil- low. 3 Floppy eyelid syndrome is found to be highly correlated with a diagnosis of obstructive sleep apnea, which is thought to be due to the similar pathophysiolo- gy of decreased elastin content of the respective tissues. 3 Supportive therapy is usually sufficient, utilizing eye shields or lid taping with lubrication and anti- inflammatory therapies. Horizontal lid shortening and other surgical procedures can also be useful for select patients seek- ing a more permanent solution. Foreign body sensation is a com- mon and significant symptom that should not be overlooked. Although lip- id and aqueous deficient dry eye are the most common culprits, don't let these underlying anatomical conditions slip by and continue to cause your patients unnecessary discomfort. EW Paul Hammond, OD is a Consultative Medical Optometrist specializing in Ocular Surface Disease and Glaucoma in Coon Rapids, Minnesota. He is a graduate of the Illinois College of Optometry, and completed his post- doctoral residency in ocular disease at Bascom Palmer Eye Institute at the University of Miami.